Birthplans and Expectations

Just a few highlights from the OB-GYN-L list, in a thread dated last October, “Birthplans and Expectations”. Most of the posts can be found here.

In this thread, OBs discuss amongst themselves the issue of women forming their own birth plans. (Quelle horreur!)

Easily panicked control-freak Steven Richman opened the proceedings:

hello listers…….very busy day today and last pt. presents me with her “birth plan” at 36 weeks. The plan was entirely reasonable and certainly within the scope of how we practice……As I was tired and she was only 18, I kinda freaked and told her that we would not honor the plan and that the Dr/pt relationship requires mutual trust etc. etc…. With over 20 yrs of experience I truly feel I have gone along with the ebb and flow of obstetrical practice and procedure …….But I object to being put in a position where the “well-informed customer” feels it necessary to dictate the mode of operation.

How would you have responded to Richman? Here’s what some of his colleagues said:

Garry Siegel:

My ideal birthplan:

The patient chooses the color of the baby’s room and the baby’s name.

Eberhard Lisse:

I use the Ontario ANC record and it has a check item “Birth Plan”. When I reach the item I say “We don’t do that here.”, tick it off and move on.

John Provatopoulos:

When patients ask me how I feel about a birth plan, I tell them the best birth plan I can think off is that the birth will be a happy occassion for everyone involved and will result in the birth of a healthy baby; then i tell not to be to be to uncompromising and inflexible in thier expectations as they are just setting themselves up for disapointment and feelings of having failed.

[later]

El are you saying there may be a corelation between the worsening perinatal mortality rate in the U.S. and the proliferation of birth plans, you may be on to something, someone should do a randomized controlled clinical trial.

Dr Ainsworth:

I’ve always seen the downside of birth plans to be that anything a patient expressly wished to avoid would be by a fluke of nature absolutely necessary during her delivery. It’s like the stars line up against them and our attempt to meet their expressed needs.

Louana, a midwife:

I think, IMHO, that the point of the birth plan is being missed in this conversation. Hospital routines and how they are applied in the L&D unit in many places put women in the position of being treated like an object without choices or rights. Essentially the birth plan, although it looks like something else with it’s check lists and all that, is a request to be treated like an individual and give the parents the respect that the miracle of their own individual bringing a child into this world deserves.

Dr Anna Meenan:

I would not look on it so much as “dictating the mode of operation” as expressing her preferences for the way she hopes the most important event in her life will be allowed to proceed. I find that quite reasonable and wonder why anyone else wouldn’t, especially if the plan was quite reasonable and well within the scope of your practice. You speak of mutual trust. Does that mean she must trust you to know what her preferences are? Most docs I know do not have ESP. I wonder, if her birth plan called for induction at 39 weeks, early amniotomy, high-dose pitocin, forceps, and a midline episiotomy, would you accuse her of dictating the mode of operation?

Eberhard Lisse, responding to Dr Meenan:

Anna,

Blah Blah Blah.

Sue, a midwife, replied:

Translation-I do no have respect for you enough to listen to your wishes, try to accommodate them and help/encourage you (to do what your body does naturally on its own, big secret)to do one of the most important things in your life in a way that you desire. Oh and by the way, thanks for choosing me and paying me to care for you!! Flame away.

The response from Eberhard Lisse?

Hey, isn’t it dangerous to fly a broomstick with poor eyesight?

These are mostly USAn contributors, but I can state from experience that the attitudes amongst my colleagues here follow a similar range. Some accept that women have bodily sovereignty, even embrace the idea; many don’t. And you can’t tell by looking at them.

So. Yeah. Pregnant readers: you might want to have an in-depth chat with your care provider about their attitude to you having control over your own body.



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31 replies

  1. What I found so horrible there was the lack of respect in the way they referred to patients and their needs, and their lack of respect for those who did acknowledge that women have some interest in managing their labour.
    When I was pregnant I was told by the midwives that the hospital ‘doesn’t accept’ birth plans because they made women feel bad when they didn’t go according to plan. Rot, of course, but knowing your health care provider doesn’t respect your bodily integrity doesn’t change the limits of choice – I just went into labour knowing my needs (no doubt framed as preferences) wouldn’t be respected and hey, they weren’t!

  2. A relative was told by her doctor that he didn’t read birth plans. Fortunately she didn’t want one.
    A friend was told at a c-section info night that they’d ‘chosen a ceasar when they chose their doctor’. Unfortunately she chosen a doctor on the grounds that he had space in his calendar for a patient, she’d rung several others after she got pregnant and they were all booked up. “Choice” in this situation is a furphy.

  3. Poops! I wish you had posted this last week! I just did a university assignment on Foucault and childbirth and that would have been useful.

  4. why don’t the comments from some of the doctors surprise me? it also doesn’t surprise me that most of them are from the US.
    who are usually the policy makers when it comes to the use of birth plans in hospitals? generally the consultants? (where, of course, you have to give birth – heaven forbid you get ideas about doing that sort of thing at home!)
    ps. happy international midwives day for yesterday 😉
    lyndals last blog post..ps.

  5. I’m glad you brought up this topic Lauredhel, I thought I’d mention that annoying (to me) OMG Toilet Birth story that was in the papers today. When I was younger (yes going into oldie mode), one recognised that yes, births can go hilariously fast on some occasions and sometimes people have to give birth in funny places, like in taxis, by the side of the road. It’s not very nice or comfortable for THE MOTHER, but generally ppl treated it as an exciting story to dine out on afterwards.
    Not so this hubby who seems to be trying it on to get as much OMG going as possible to try for a nice juicy lawsuit. He’s been interviewed moaning and bitching about how HE suffered and how bad HE felt and even how he had to “catch the baby” – FFS you’d think that’d be a high point in most people’s lives, what a fount of negativity.
    I wonder how he’s coping with an actual baby (thinking of the other post on parenting skills!)

  6. I’m wondering whether more detail will emerge on that story, Helen, as it already seems to have changed quite significantly (not blaming the complainers here, necessarily; it could be purely media invention).
    One report says that they were attended by midwives for the birth, and that the complaint was primarily that the labour started spontaneously and went so fast that they didn’t get their “expected” birth which was to include an induction and an epidural.
    Yet the hospital seems kinda abject in their quoted response – whatever happened to the usual dismissive response when someone got an operation they didn’t want or need, the one that goes: “All that matters at the end is a healthy baby”?
    The one biggest determinant of whether a complaint against medical services is laid is communication, and it’s possible that the communication and support went awry around this birth. (It’s not the only determinant, though.)

  7. I just heard that story on the radio. Without commenting on their particular circumstances, my main peeve, having had pretty quick deliveries myself (I still remember the midwife saying “jeez it’s coming like a steam train”), was that I could have saved myself the bovver and had them at home if it weren’t for all of the “Danger! Danger!” messages I was getting from everyone around me. Having a doctor as Uberpatriarch doesn’t help either. It reflects very poorly on said doctor if some no-name feral daughter-in-law refuses hospitalization for her birth.

  8. I am so lucky, I had an obs that was incredibly respectful. I couldn’t get my head around a birth plan – my birth plan was GET IT OUT, with as little intervention as possible. We pretty much managed that each time. But then I had a doctor who I genuinely believed was in the same head space as me – she operates in a birth centre which is remarkable enough.
    It was the midwives who got me through the labours though, not the obs. Given that doctors are usually only there for the finish line, as it were, it seems insane that they are the ones vetoing birth plans.
    I would give a little credence to the “setting up for disappointment” theory (not so much as to ban birth plans) though. Depending on where the person gets their information, I think it’s possible people can have quite unrealistic expectations. I have a friend who was angry about her (emergency) caesar and screamed at her mother “So what happened before they had caesars???” and her mother calmly said “mother and baby died dear.” In her case it was true.
    It’s all noise though, compared with the general total lack of respect for women and midwives. Staggering that people daily involved in such an emotional process could be so cold and indifferent.

  9. fergus:

    Poops! I wish you had posted this last week! I just did a university assignment on Foucault and childbirth and that would have been useful.

    Ah, Foucault and the medical gaze? I have a picture around here somewhere to show you. Give me a little while to dig it out. (Off to read bedtime stories first.)
    Lauredhels last blog post..Reader question: your pipe dream in print?

  10. I’m appalled by the way that in the first quote the doctor felt more entitled to ignore the birth plan because the patient was only 18. It shows a really horrible attitude towards teenage mothers.

  11. I agree about the father in the Sydney TV story. His wife never said a word. He has a healthy baby and the birth was (obviously!) easy – what more does he want? Silly twat!
    I did think that the hospital was handling the sitch better than some of the PR disasters we’ve seen recently.

  12. “A friend was told at a c-section info night that they’d ‘chosen a ceasar when they chose their doctor’. Unfortunately she chosen a doctor on the grounds that he had space in his calendar for a patient, she’d rung several others after she got pregnant and they were all booked up. “Choice” in this situation is a furphy.”
    Oh yes? You can always choose not to use a doctor. That’s a genuine choice, not a furphy. Of course it’s one that people largely tend to ignore, but your friend could have called some independent midwives.
    The comments of the doctors make me so sick – I can’t believe they’re still equating midwives with witches. Oh wait, it’s not that unbelievable. The attitude of the medical professional to birth is horrendous.

  13. I’m appalled by the way that in the first quote the doctor felt more entitled to ignore the birth plan because the patient was only 18. It shows a really horrible attitude towards teenage mothers.

    Argh! Totally! “She was only just an adult, so I made damn sure I didn’t treat her like an actual person.”

  14. I have to admit I’ve started from the assumption that no-one is going to respect a birth plan, and that I ‘chose’ the birth when I chose the hospital and doctor. (The scare quotes, of course, are because there’s not really much of a choice out there.)
    The elite, prestigious, private hospital that most of my cashed-up friends are, have or would choose to deliver in has as 50% C-section rate – 60+% for primagravidas. When you look at those statistics, you have to know that you’re looking at a particular standard of care. For that hospital, c-sections are the norm. To expect a low intervention ‘natural’ birth, especially as a prima, would be rather like going to a stakhouse and expecting a vegetarian option.
    That said: those statistics aren’t publicised, most women wouldn’t know or think to ask for them and they’re sure as hell not going to offer them unsolicited. In an era when our state average for c-sections is 37% (in ’06, the most recent year available), it’s not like there’s many alternatives. And you know as well as I do that women are scared or logisticed out of home births. So when I say I knew what I was choosing – I don’t mean to judge those who don’t. The odds are incredibly stacked against us. I got lucky, both geographically and generally. And I won’t bother with a birth plan, because I have a GP whose philosophy is already in line with mine.
    All of that said, then, I’m really conflicted about the existence of birth plans. If a hospital is just going to ignore it anyway – and let’s face it, they are – I think I’d prefer to know that upfront. I would prefer to have my first interview with my OB, and be told flat out ‘my section rate is X, I induce at Y weeks, I believe in episiotomies as standard’. So that I had time to change my caregiver. To encourage birth plans, when anyone who knows what to look for can see that it is the doctor, and the hospital, that will dictate the birth – well, it seems dishonest and potentially heartbreaking.
    I’m not offering that as a solution to the real problem (‘oh, just accept that you won’t control your own birth!’) but I wonder whether the proliferation of birth plans is just masking the rise and rise of medicalised high-intervention births? Whether they just exist to convince women that they do have some autonomy and that their eventual c-section was an emergency and not an inevitability?

  15. Thank you for posting this story. It is really troubling to read the OB’s comments with the same old stereotypes towards midwives, it really disturbs me.
    I have the good fortune to live where I have access to one to one midwifery. I wish everyone had both good birth options and good understanding and education about those options.

  16. Is the level of misogyny worsening in the obgyn world? The degree of arrogance and threat the male obs showed towards their female colleagues especially the midwives is horrifying and unacceptable.

    The awful Howard Government legacy in this country of trying to coerce people over 30 into buying health insurance has added to the c-section rate in Australia. Wanting to get value for money out of the high cost for insurance many intelligent and well resourced women go for a private obs (despite the fact they will still end up thousands of dollars out of pocket) rather than use the free, public hospital, midwife dominated family birthing units.

    Perhaps the discussion list you quote from should be obligatory reading for all newly pregnant women who are making choices about their pregnancy care?

  17. Rebekka, while I agree that my friend could have chosen an independent midwife (because unlike me she would have the resources to pay for it) she needed a doctor in a hospital because:
    a) her baby was breech and finding someone who’s prepared to (and insured to) attend a natural breech birth is difficult, we get here into the territory of what women are “allowed” to do.
    b) she knew bugger all about birth politics before she got pregnant. In fact, she found out most about birth and c-section rates when she was about 36 weeks pregnant and it was a bit late to change tack. You might suggest that she should have done her homework, but frankly, if you don’t have heart disease you don’t read up “just in case” so you can ask all the right questions when you get to see a specialist. She trusted the GP who referred her to give her appropriate information, and then she trusted her Obstetrician. Most people do. Blaming an individual for that is completely unreasonable when there is a massive systemic problem.
    c) She was 38 when she gave birth, which all by itself moves her into the “risky” category, which makes it difficult to get the sort of birth you might want.

  18. “frankly, if you don’t have heart disease you don’t read up “just in case” so you can ask all the right questions when you get to see a specialist.”
    Yeah, you do if you want to be an informed person who takes responsibility for their health. There is no way I wouldn’t read up on heart disease and make sure I was questioning my care – doctors are human, medicine is very often not evidence-based, and my health is my responsibility.
    I realise there is a massive systemic issue, I was not blaming your friend for choosing a doctor or for having a c-section. I was disagreeing with you that there are no available choices just because doctors are booked out in advance – midwives are a choice.
    There are midwives who will still deliver breech babies – there are also other options to try to turn them before the birth. And a midwife would not automatically “risk out” a woman based solely on age.

  19. My point is that you aren’t reading up on heart disease now, when you don’t have it, nor are you reading up on all of the details on cancer, despite the fact that heart disease and cancer are very common and may well happen to you at some stage. You’d be relying on your GP to diagnose you, and refer you to an appropriate specialist. You would also do some research of your own, but you’d do it after you were diagnosed. Not now.
    When women get pregnant (here in Victoria anyway) they need to book into a hospital or an alternative caregiver pretty much immediately, because there is a baby boom on and the public and private hospitals, the private midwives, and the birth centres all get booked out. You don’t get time to read around and weigh your options. Finally, because you have to book in straight away, and you generally don’t tell everyone about a pregnancy until 12 weeks, you don’t get everyone telling you birth stories when you’re in the decision making phase. All of this adds up to “why I tell my friends why I chose a birth centre even though they aren’t pregnant or planning to be any time soon”. I had the good fortune to have both a GP and a sister in law explain the birth centre option so it no longer sounded scary.
    Most women don’t do much research on maternity care before they get pregnant unless they have some reason to (like watching a close friend or relative being treated badly by their doctor) they tend to do what is recommended by health professionals, their friends, parents and other relatives. If everyone you know has had their babies in a private hospital with a specialist, and this has resulted in healthy babies, and no one has complained about their treatment, you’ve got no reason to question choosing this model of care for yourself.
    There are circumstances where women do genuinely need doctors, and saying “get a midwife” isn’t the answer.

  20. Yeah, you do if you want to be an informed person who takes responsibility for their health.

    Really? Do you read up on every medical condition known to humankind, just in case?
    I live with several chronic conditions. Just keeping up on the basics for them takes enough of my energy and time — the suggestion that I should also be up on every other medical condition I could potentially come down with is just ludicrous.
    It will vary — such is life — but people generally manage their time as they see fit — not everyone has the time or the mental energy to be an expert on anything that can happen to their body. This is why we have doctors: to be the experts for us, to ensure that proper care is taken in every case.
    As to the specific issues, midwifes are *not* a choice for a good many people, whose insurance does not provide for them and whose financial condition does not allow for them. I understand trying to remind people that alternatives exist; assuming that their existence means that they are within reach for every person, however, doesn’t sit right.
    If I have misinterpreted, I apologize.
    amandaws last blog post..If you give a cat a bath…

  21. “frankly, if you don’t have heart disease you don’t read up “just in case” so you can ask all the right questions when you get to see a specialist.”
    Yeah, you do if you want to be an informed person who takes responsibility for their health.

    As amandaw said, really? You read up on conditions you don’t have and don’t particularly expect to have?
    I do take your point that women who know that they want children at some point are subconsciously choosing to be under-informed because of a general insouciance about birth until one personally becomes pregnant, and that encouraging more discussion about birth practises in the pre-pregnant cohort would be beneficial in enabling women to be more insistent on their perinatal rights.

    As to the specific issues, midwifes are *not* a choice for a good many people, whose insurance does not provide for them and whose financial condition does not allow for them.

    We’re fortunate in the financial impact of choosing midwives here in Australia (and it’s similar in the UK): hospital-based midwife centres are common in our capital cities and larger regional cities and are fully covered by our national health system, so many women can have a midwife birth on the grounds of a hospital without paying a cent.
    I’m not sure, but I believe some of the hospital Birth Centre midwives here in Oz even offer a home birthing service within the hospital district?
    Private midwives are covered by all private health insurers here (our government regulates private health insurers more stringently than in the US, and individuals choose their own insurers – it’s not employer-based).
    Ugh. I do hope your fellow voters manage to elect a President who’ll really do something about reforming your health system, amandaw.

  22. Private midwives are covered by all private health insurers here

    I’m not so sure about this. At least one major insurer has just withdrawn all coverage for homebirth – because it’s not an “inpatient procedure”.
    Perth does have a small, publicly-funded Community Midwifery Programme which does homebirths, but it is small, and women are risked out at the drop of a hat. Many other areas have no access to funded homebirth. Women who can afford it end up using their baby bonus if they want an indy midwife, money which would otherwise be useful to pay rent and buy food while they’re on their unpaid maternity leave.
    Hospital “midwife” births are a mixed bag. Many midwives work very, very thoroughly within the medical-interventionist model. And again, women get risked out of midwifery-run units – even just for arbitrary things like weight over 100 kg (regardless of health and birthing history).

  23. I hadn’t heard about the insurer withdrawing coverage for home-births. That certainly constrains many people’s options.

    Hospital “midwife” births are a mixed bag.

    Yes. I was trying to draw a strong line of demarcation between obstetrics ward midwives and hospital-based Birth Centre midwives, and I didn’t manage to, and as you say the Birth Centres are hedged about with many restrictions regarding risk management as well.

  24. Sorry, I misread because I’m very very busy – I thought it said was saying if you DO have heart disease you don’t read up “just in case” etc
    Stupid me!
    However, I still disagree with this:
    “You’d be relying on your GP to diagnose you, and refer you to an appropriate specialist.”
    Because I wouldn’t be – if I have symptoms, I’m researching my symptoms until I have a good idea what to ask, what tests to request and what might be wrong with me. Type “misdiagnosis death GP” into google, and you’ll probably have a fair idea why. I am responsible for my body and my health, and I can’t hand that responsibility over – although I can certainly consult with an expert, and will if the situation requires it. I can’t remember the last time I had something wrong with me and had it accurately diagnosed by a GP – in fact, I can think of a dozen or more times when something wrong with me was blatantly misdiagnosed.
    And yes, of course there are situations where women need a doctor – I was not suggesting there aren’t. All I was saying was midwives are a choice. Suggesting that women don’t have a choice of caregiver because doctors are booked out isn’t true. Midwives are an option for women in Australia with uncomplicated pregnancies, in one form or another, whatever your insurance situation.
    Pregnancy isn’t a disease – it’s a normal physiological condition, and as feminists I think we should be talking more about the medical profession’s patriarchal control over our bodies, particularly when it comes to birth, so that when women do get pregnant they’re not so bereft of information as to suppose their best option for an uncomplicated pregnancy is an obstetrician. That’s why I love these posts so much – perhaps they’ll influence someone to question whether a doctor really is the sort of care they want during a birth.

  25. My friend is a doula, and she tells me that the birth plan is actually a legal document in Australia. I’ve been meaning to investigate that further but have not had the time. She says that the midwife or doctor can only get out of not abiding by it if they have not read it. Beware a midwife entering your room if the first thing she says is, “I haven’t read your birth plan.” She may well have read it, but is legally protecting herself, or intends to disregard it. A good, carefully worded birth plan takes less than a minute for a professional to read. If they say they haven’t read it, have a summary handy.
    Doulas, by the way, are worth their weight in gold. They are totally focussed on your physical and emotional welfare in labour, have lots of drug free tricks for pain relief, and can be your advocate when you are busy with the herculean job of “getting it out”.
    I won’t repeat myself, but here’s my rant on women educating themselves about childbirth. Though I’ll agree, unless you’re planning a baby there’s no research time anymore 😦
    With my first child,ten years ago, I knew nothing. I naively booked myself into the Royal Women’s in Melbourne because that’s what I thought I was supposed to do. I saw a different doctor each checkup and left my modesty at the hospital doors each time. One day, I asked an elderly OB whether it would be ok for me to go on a camp for zoology when 6 months pregnant. He said, “Of course!” Then looked me right in the eye and said, “YOU’RE NOT SICK.”
    This was a new thought for me. Not sick. He’d started an avalanche of questions: If I wasn’t sick, why was I going to a hospital? If I was healthy, why was I being treated like a human pin cushion? Why was I being given repeated invasive medical examinations? Why was I being TREATED as though I were in some sort of danger?
    That was enough unanswered questions for me and I coped the way I always do – I hit the library. I don’t remember everything I read, but one title stayed with me, The Baby Machine edited by Jocelynne A. Scutt. The whole world of the medicalisation of childbirth is laid out before you in that book. I finished it with my eyes wide open.
    Luckily, ten years ago there was not a baby boom on and I was able to transfer to the Royal Women’s Family Birth Centre at 7 months. There I had a fantastic natural birth attended only by midwives whom I got to know over two months. My aunts who describe their labours in terms of the pain relief they had, were astounded to hear that it was drug free and I gave birth to my son standing up.
    With my last one (2006) you practically had to book on your conception date to get into a birth centre, so my sympathies are with anyone who finds themselves with an unplanned pregnancy, there’s no time to research at all 😦
    I would no longer recommend the Royal Women’s birth centre, it is just another hospital ward now – I checked in but had an argument with a midwife half my age about milo so checked out… but that’s another story. I ended up at the Mercy Family Birth Centre with the same midwife I’d had ten years ago **happy!!**, and a doula and student midwife that I knew personally. My husband and son were also there, my husband caught his daughter and hearing my son call out, “It’s a girl!!” was indescribably beautiful.
    However, I STILL had altercations with them about hospital policy – they wanted me to labour with a cannula in my arm. I fought, I got second medical opinions, I won. I could only do that because I was well informed of my rights and treatment alternatives.
    I don’t want to give the impression that I’m one of those women who think that every one can have a natural birth if they are left alone. I don’t think that. Medical intervention saves lives, that’s a no brainer! However at the moment, medical intervention in the form of “managed childbirth” is causing half the problems it’s fixing. 😦
    I think OB’s in Australia are slowly coming around. Almost every woman I know is having babies at the moment, not all of them are as militant as I about midwives only, and many of them have had great births with their OBs.
    I think the most important thing of all is trusting your health providers. If my midwife had told me that my baby had to come out surgically NOW, I would have known that there was no other alternative. I would have been happy to trust her judgement. I would not trust the judgement of an OB who wouldn’t read a birth plan. I would assume they had issues with control. I would assume that once I went into labour I’d be relegated from the status of individual human being, to ambulatory pelvis that needs to be managed.
    Australia is getting better, but we still have a long way to go. My next one will be at home 🙂
    Emmas last blog post..Voluntary euthanasia or murder?

  26. Ah, Foucault and the medical gaze? I have a picture around here somewhere to show you.

    I finally got to this, fergus! It’s here.

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